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SHOULDER Solutions by Tornier A EQUAL IS™ RE V ERSED FR AC T U RE S U R G I C A L T E C H N I Q U E Aequalis™ Reversed Fracture surgical technique AEQUALIS™ REVERSED FRACTURE SURGICAL TECHNIQUE SHOULDER PROTHESIS Aequalis™ Reversed Fracture table of contents NICE LOOP DESCRIPTION P. 4 1. PRODUCT DESCRIPTION 2. THE DOUBLED SUTURE NICE KNOT TECHNIQUE IMPLANT P. 6 1. INDICATIONS 2. CONTRE-INDICATIONS SURGICAL TECHNIQUE P. 7 1. PREOPERATIVE PLANNING 2. PATIENT POSITIONING 3. SURGICAL APPROACH 4. FRACTURE EXPOSURE 5. GLENOID EXPOSURE AND PREPARATION 6. PREPARATION OF THE HUMERUS 6.1 Humeral Reaming 6.2 Drilling of diaphyseal Sutures Holes 6.3 Positioning of the Trial Stem 6.4 Placing the Bone Graft 6.5 Cementing the Implant 6.6 Placement of Final Humeral Implant 6.7 Impaction of Humeral Insert 6.8 Reduction 6.9 Tuberosities fixation 6.10 Trial and Closure 7. REHABILITATION 8. COMPLICATIONS 9. AEQUALIS™-REVERSED NON REVERSED HEMI-PROSTHESIS ADAPTOR TECHNIQUE 9.1 Preparation of Metaphyseal Implant 9.2 Affixing Union Screw 9.3 Implantation of Adaptor 9.4 Impaction of Humeral Head 10. ASSEMBLY OF PROSTHESIS HOLDER 10.1 Prosthesis Holder Components 10.2 Assembly of Height Gauge 10.3 Assembly of Prosthesis Holder 10.4 Assembly of Retroversion Rod COLOR CODING P. 24 INSTRUMENTATION P. 26 IMPLANTS P. 28 Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 3 nice loop description 1. DESCRIPTION The Tornier NiceLoop™ is the dedicated solution to perform the NiceKnot, a sliding and self stabilizing knot, invented by Pascal Boileau M.D, PhD, in Nice (France). For more information about the NiceKnot, Please refer to the WhitePaper “The Doubled Suture NiceKnot” (ref. UKNA121) NiceLoop™ Properties: • The NiceLoop™ is tied as a doubled-over suture. • The tightening process of the NiceKnot can be stopped and resumed at any stage, as the knot is self stabilized (preventing from slippage). • The NiceLoop™ can be used in a variety situations: -Tuberosities Fixation during Hemi or reversed arthroplasty for fracture - Cerclage for Humerotomy or Femorotomy - Fixation of Bone Fragments (i.e Butterfly). • By combining a simple initial knot with 3 half hitches, the NiceKnot provides knot security without an excessive amount of complexity and bulkiness. NiceLoop™ Specifications: • Available in 3 colors: Solid White, Solid Green, White/Green • 60cm (24 inches) long loop (doubled-over) • Braided PTFE Impregnated Polyester Fiber Nonabsorbable Surgical Suture • Needle: KAC-25, 1/2 Circle, K-Point (49mm). Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 4 2. THE DOUBLED SUTURE NICE KNOT TECHNIQUE Fig. 1a • The following is a step-by-step description of how this knot is made: • Use a Nice loop • Pass the suture around the tissues to be fixed (Fig. 1a) • Use a square knot using the loop on one hand and the needled limb on the other (Fig. 1b) • Cut the needled limb (Fig. 1c) • Open the loop and pass both free limbs through it (Fig. c), then dress the knot by making the loop smaller (Fig. 1d). • When ready to secure the involved tissues, tighten down the sliding knot either by pulling the two free limbs apart (Fig. 1e) – as done during open surgery – or by pulling the free limbs (acting as the post) back towards you – which is most useful during arthroscopic surgery. NOTE : As with other sliding knots, while the post is being pulled back, the knot can be helped down manually to reduce the traction forces seen by the tissues around which the sutures are sliding. Another way to reduce such traction forces is pulling the post’s two free limbs separately in alternation (but still in the same axis). - Finally, perform three alternating half-hitches or surgeon’s knots using the two separated free limbs (Fig. 1e). This precludes the possibility that the free limbs slide back out of the loop, thus securing the knot definitively. * Secure the Knot definitively with the three alternating half-hitches. Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 5 Fig. 1b Fig. 1c Fig. 1d Fig. 1e implant 1. INDICATIONS AND CONTRAINDICATIONS The Aequalis™ Reversed Fracture Shoulder Prosthesis is indicated for patients with a functional deltoid muscle as a total shoulder replacement for the relief of pain or significant disability following arthropathy associated to a grossly deficient rotator cuff joint: • In case of traumatic or pathologic conditions of the shoulder resulting in fracture of the glenohumeral joint, including humeral head fracture and displaced 3-or 4-part proximal humeral fractures, or • In case of bone defect in the proximal humerus. The Aequalis™ Reversed Fracture Shoulder Prosthesis is also indicated for prosthetic revisions with a grossly deficient rotator cuff joint when other treatments or devices have failed. The Aequalis™ Reversed Fracture Shoulder humeral stem is used in association with the glenoid components of the Aequalis™ Reversed Shoulder Prosthesis. The Aequalis™ Reversed Fracture Shoulder humeral stem is for cemented use only. A complete list of contraindications can be found in the “Instructions For Use“ packaged with the implants. Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 6 surgical technique 1. PREOPERATIVE PLANNING Thorough patient evaluation with history and physical examination is advised. Evaluation of the contralateral shoulder should be done since there can be limited range of rotation with a reversed prosthesis. The deltoid muscle must be evaluated by clinical examination. Weakness of the deltoid does not constitute a strict contraindication to a reversed fracture prosthesis. The preoperative studies should include computed tomographic (CT) scan to classify the fracture, determine the displacement and status of the tuberosities, evaluate indirectly the status of the rotator cuff by analysis of fatty infiltration of the muscles and assess the glenoid bone stock. Bilateral X-rays of the whole humerus allow evaluation of bone loss in comminuted fractures and help the surgeon estimate the approximate stem height of the prosthesis by comparing measurements of the contralateral side of the humerus with measurements of the fractured side. 2. PATIENT POSITIONING Patient is placed in a beach chair position with the shoulder off the table. The patient is vertically inclined to the angle determined according to the surgical approach selected. Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 7 surgical technique 3. SURGICAL APPROACH The superolateral approach is usually recommended for these cases. Patient is placed in a beach chair position. A longitudinal incision is made, starting from the acromioclavicular ligament and running distally for 4 cm following the anterior edge of the acromion. The anterior and middle deltoid muscles are separated with respect to the lateral edge of the acromion. It is important to be careful with the dissection to avoid an axillary nerve injury since this nerve is found about 4 cm away on the lateral side of the acromion. (Fig. 2) Fig. 2 The deltopectoral approach can also be used. 4. FRACTURE EXPOSURE The first step is to identify the fracture fragments. (Fig. 3a-b) Once the fragments have been identified, the supraspinatus tendon is resected to the glenoid rim. The humeral head fragment is removed and a tenotomy of the long head of the biceps is done. The intra-articular portion is then resected. The ligament will be tenodesed with suture to the transverse ligament before closing. Fig. 3a The greater tuberosties is mobilized posteriorly and 2 green Nice Loop sutures are placed in Infraspinatus and 2 white Nice loop sutures are placed in Teres Minor. For each tendon, enter the first one from inside to outside and cut the needle of the suture. Enter the second suture from outside to inside leaving the needle in place in order to fix the LT afterwards. NOTE : For each tendon, the sutures are clipped with a Kelly clamp in order to ease their identification and manipulation. Fig. 3b Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 8 surgical technique 5. GLENOID EXPOSURE AND PREPARATION The characteristics of the fracture usually allow easy exposure of the glenoid. (Fig. 4) The various surgical steps for exposure and implantation of the baseplate and glenoid sphere are described in the Surgical Technique of Aequalis™ Reversed (UDXT151 et UDXT145): Fig. 4 NOTE : •Instability is a considerable risk when a reversed prosthesis is used for fracture as a result of: - Lack of reliable anatomic landmarks • To avoid instability: - Inferiorly position the base plate. - Position the humeral implant to the correct height using the greater tuberosity as a landmark. The prosthesis should not be implanted lower than the superior edge of the greater tuberosity. - The greater tuberosity must be reduced with the arm in neutral position. Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 9 surgical technique 6. PREPARATION OF THE HUMERUS 6.1 Humeral Reaming The medullary canal of the humeral shaft is progressively reamed with reamers of increasing diameter (7, 9, 11, 13, 15 mm) until the reamer contacts the cortical bone. (Fig. 5) Fig. 5 The last reamer used determines the size of the humeral stem. Each diameter corresponds to a color code that easily identifies which instrument to use. (Fig. 6) The reamers are marked at depths that correspond to the necessary reaming length according to the chosen stem. NOTE : In case of revision, it is important to remove as much cement residue as possible to not interfere with tuberosity consolidation. 6.2 Drilling of diaphyseal Sutures Holes Fig. 6 Two holes are drilled laterally in the bicipital groove 2 cm under the fracture site using a regular 2.7 mm drill bit (not included in instrumentation). The first Nice loop suture is placed from outside to inside on the anterior hole, this suture is then placed from inside to outside in the posterior hole. This suture will be used to fix the infraspinatus. The second Nice loop is placed in the posterior hole from outside to inside and from inside to outside into the anterior hole. This suture will be used to fix the subscapularis. They will be used as a shroud to secure the fixation of the tuberosities at the end of the procedure. (Fig. 7) Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 10 Fig. 7 surgical technique 6.3 Positioning the Trial Stem 6.3.1 Retroversion The trial stem is introduced in the medullary canal. Adjust the retroversion with the retroversion rod. It has to be parallel to the patient’s forearm. The guide retroversion is adjusted to 20° relative to epicondyles (25° in relation to the forearm). The second retroversion rod can be used as an orthogonal landmark by placing it on the wrist. A mark is made with electrocautery at the lateral fin of the stem and will be used as a landmark to position the definitive implant (Fig. 8 - zoom 1) zoom 1 zoom 2 Fig. 8 NOTE : The assembly of the guide is detailed pages 24-25. Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 11 surgical technique 6.3.2 Selecting the Height To select the proper height, place the superior aspect of the trial implant to the superior edge of the reduced greater tuberosity. (Fig. 9) Inspect the reduction of the greater tuberosity for confirmation of proper positioning of the stem. The reduction with trial implant can be done once the prosthesis holder is removed. The prosthesis must be stable upon insertion and before the tuberosities can be reduced. If the stem sits too low, insert the next larger trial stem. Fig. 9 Once the appropriate height has been achieved, position the height gauge on an anatomic landmark. The height is then read on the ruler ( (Fig. 8 - zoom 2) This reference will be used again when the final implant is put into place. 6.4 Placing the Bone Graft Bone grafting is recommended to enhance consolidation of the tuberosities. Two bone grafts are harvested from the humeral head in the bone graft cutter. In case of revision, or if the bone quality of the humeral head is not sufficient, autografts or allografts can be used. Fig. 10 Fig. 11 Prior to cutting the graft, ensure that the thumb screw is unscrewed. Position the humeral head in the bone graft cutter. (Fig. 10) The graft is cut by firmly tightening the handle. In the case of exceptionally hard bone, a mallet can be used to strike the clamp. The dural part of the harvested graft is cut with a gougeforceps before it is removed. (Fig. 11) Tightenen the thumb screw to remove the graft.(Fig. 12) Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 12 Fig. 12 surgical technique Once cut, the graft is placed in the window of the final prosthesis before it is placed in the humerus. (Fig. 13) Fig. 13 6.5 Cementing the Implant After placing the diaphyseal plug, the humeral canal is dried and cement is injected using a large syringe. A surgical drain can be temporarily placed in the medullary cavity. Fig. 14 Ensure that the sutures into the diaphysis are sliding properly before complete drying of the ciment. (Fig. 14) 6.6 Placement of Final Humeral Implant Insert the final prosthesis using the prosthesis holder. Adjust the height to the same level as defined during the trial process. Adjust retroversion by aligning the lateral fin of the prosthesis with the previously made mark. This is then confirmed using the retroversion rod attached to the prosthesis holder. (Fig. 15) Excess cement is removed with a curette. Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 13 Fig. 15 surgical technique 6.7 Impaction of Humeral Insert After the cement is dry, the selected polyethylene insert is positioned by aligning the insert‘s orientation notch with the metaphyseal pin. Reduction with different sizes of trial humeral inserts can be done to find the best muscular stability. Once the final thickness is selected, the metaphyseal component is thoroughly cleaned and dried. Insert a metaphyseal plug and screw it into the base of the metaphysis. The final insert is impacted into the metaphysis or on the lateralized spacer with the humeral insert impactor. (Fig. 16a-b-c) Fig. 16a The prosthesis is then reduced. If reduction is difficult, a prosthesis reducer can be used. NOTE : If a lateralized spacer is used, the spacer is impacted into the metaphyseal cup with the humeral cap adaptor impactor. After impaction, the central securing screw is inserted and fully tightened with the 3.5 mm screwdriver, thus securing the spacer onto the metaphysis. 6.8 Reduction Before joint reduction, the “Lasso Maneuver” is performed by placing the sutures around the prosthesis neck at the level of the polished area (Fig. 17). Once the sutures are in place around the stem, the joint can be reduced properly. Fig. 17 Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 14 Fig. 16b Fig. 16c surgical technique 6.9 Tuberosities fixation 6.9.1 Place Horizontal Cerclage Sutures around the Greater Tuberosity Fixation of the tuberosities begins with fixation of the greater tuberosity. The arm is placed in neutral position. A clamp is used to pull the greater tuberosity anteriorly, reducing the greater tuberosity to the prosthesis. (Fig. 18) Using the Nice Knot technique (REF p5), tie the two Niceloop without needle around the greater tuberosity (one superior green, one inferior white), to secure the greater tuberosity to the prosthesis. (Fig. 18) NOTE : Tie the knot outside and strengthen it before leading the knot to the point of fixation you want. The Nice Knot will be finally secured by performing 3 alternating half-hitches or surgeon knots. Fig. 18 6.9.2 Place Horizontal Cerclage around the Lesser Tuberosity The next step is to reduce the lesser tuberosity. The two remaining horizontal Nice Loops with needles (one green, one white) which had initially been passed through the posterior rotator cuff tendon and around the prosthetic neck, are then passed through the subscapularis tendon from inside. The green Nice loop is passed through the superior portion of the subscapularis tendon while the white one is placed on the inferior part. Both sutures are passed from inside to outside and are then tied using the Nice Knot technique. (REF p5) The sutures thereby give lateral stability to the tuberosities. (Fig. 19) Fig. 19 Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 15 surgical technique 6.9.3 Secure the Greater and Lesser Tuberosities Final tightening creates a vertical support from the diaphysis. The anterior suture is passed though the subscapularis and tied using Nice Knot technique. The second posterior suture is placed into to the infraspinatus insertion and tied using the Nice knot technique. NOTE : Make sure that both sutures are sliding properly before performing the Nice Knot. This technique provides solid and reproducible fixation of the tuberosities on the diaphysis. (Fig. 20) Fig. 20 6.9.4 Tenodesis of the Long Head of the Biceps After resecting the intra-articular portion of the long head of the biceps, a nonabsorbable suture is passed through the tendon of the long head of the biceps. It is then reinserted in the bicipital groove. Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 16 surgical technique 6.10 Trial and Closure Peri-operative Trial Pull the arm away from the body after reduction and fixation of tuberosities to ensure that there is no "pistoning" effect. Complete separation of the prosthesis while pulling indicates inadequate tensioning of the deltoid. Abduction of the arm is performed to check that there is no impingement and that anterior elevation and abduction have been restored. External rotation with the elbow at the side (ER-1) assesses passive external rotation. External rotation with the elbow abducted (ER-2) assesses the risk of possible future subluxation. Internal rotation with the elbow at the side (IR-1) and in abduction (IR-2). Forearm must be parallel to the thorax for IR-2 trial. This reflects the patient‘s future ability to move the hand to the back. Adduct the arm to check that there is no impingement between the pillar of the scapula and the humeral implant. After reduction of the prosthesis, the coraco-biceps tendon should usually have sufficient muscular tension. Closure In the superolateral approach, the anterior deltoid is reattached to the acromion with a trans-osseous nonabsorbable suture. In the deltopectoral approach, full or partial reinsertion of the subscapularis is performed if possible. Be prepared to place a surgical drain in the sub-acromial space to reduce the risk of hematoma, as it is common in fracture cases. Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 17 surgical technique 7. REHABILITATION The arm is placed in a brace with the elbow close to the body in neutral or internal rotation. An abduction splint can be used, especially in cases of anterior deltoid detachment when the superolateral surgical approach was used. Plan early rehabilitation adapted to the status of the patient‘s bony structures and soft tissues. • Strengthen the Deltoid: Starting from the sixth week with active exercises against resistance. Strengthen external rotators with elbow close to body by means of isometric exercises against resistance. If the deltoid attachment has not been disrupted, mobility is usually rapidly recovered. • Reduce the Risk of Subluxation: Retropulsion and external rotation must absolutely be avoided postoperatively, especially when the patient is in decubitus position. Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 18 surgical technique 8. COMPLICATIONS Postoperative Stiffness In case of significant preoperative stiffness, it may be difficult to regain mobility postoperatively. Surgical arthrolysis in conjunction with capsulotomy may be required with the removal of soft tissue adhesions and possibly removal of the tuberosities. Postoperatively, the arm is usually immobilized in a shoulder abduction splint in 60 degrees abduction. Passive elevation above the splint in the scapular plane is started immediately. Prosthesis Instability This is the consequence of insufficient deltoid tension. Possible causes: • Stem positioned too low • Sphere positioned too high Good synthesis of the tuberosities increases the joint stability. In case of early postoperative dislocation, closed reduction under general anesthesia is performed. If the prosthesis is in good position with retroversion and good overall fracture alignment, then immobilization for 6 weeks normally restores stability of the prosthesis. With early recurrence of instability, surgical revision is needed to check the position of the prosthesis. Increase the humeral lateralization as necessary by adding a lateralized spacer at the level of the humeral implant. Scapula Notch Impingement between the pillar of the scapula and the humeral implant can lead to scapular bone erosion resulting in a scapular notch. This notch usually does not affect function or mobility. X-ray follow-ups are recommended. Absence of Active External Rotation The absence of the teres minor and infraspinatus due to tendon cuff tear or fatty infiltration may be the cause of loss of active external rotation. In this case one may consider a latissimus dorsi transfer to the greater tuberosity of the humerus performed at the same time as the Aequalis™ Reversed Fracture prosthesis procedure. Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 19 surgical technique 9. AEQUALIS™ REVERSED NON REVERSED HEMI-PROSTHESIS ADAPTOR TECHNIQUE Indications When during the primary surgery the glenoid bone stock appears to be insufficient to bear the reversed glenoid components, or when glenoid bone fracture occurs during the surgical procedures, the non reversed hemi-prosthesis adaptor and the union screw can be adapted to the humeral components in order to transform the Aequalis™ Reversed Fracture Shoulder Prosthesis into a non reversed hemi-prosthesis. When, in case of revision of a Aequalis™ Reversed Fracture Shoulder Prosthesis, the glenoid bone stock appears to be insufficient to implant a base plate and a sphere of Aequalis™ Reversed range again, the use of the non reversed hemi-prosthesis adaptor and the union screw allows for the transformation of the Aequalis™Reversed Fracture Shoulder Prosthesis into a non reversed hemi-prosthesis in order to avoid the revision of the humeral components.. Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 20 surgical technique 9.1 Preparation of Metaphyseal Implant Remove the polyethylene implant with an osteotome. (Fig. 21) 9.2 Affixing Union Screw Fig. 21 Union screw is screwed into the metaphysis. Tighten the screw with a 14 mm wrench (Fig. 22) or with the wrench for metaphyseal plug associated with a 4.5 mm screwdriver. 9.3 Implantation of Adaptor Fig. 22 Clean the inner part of the metaphysis carefully. The non reversed hemi-prosthesis impactor is screwed into the handle of the humeral insert impactor. Be sure to position the adaptor notch in line with the metaphyseal plug. The adaptor is then impacted with the hemi-prosthesis impactor. (Fig. 23) Fig. 23 9.4 Impaction of Humeral Head After the adaptor is in place, the exposed tapered cone is carefully dried and cleaned. The Aequalis™ adaptor cap of the selected diameter is impacted on the tapered cone of the union screw using the glenoid sphere impactor. (Fig. 24a-b) Fig. 24a Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 21 Fig. 24b surgical technique 10. ASSEMBLY OF PROSTHESIS HOLDER 10.1 Prosthesis Holder Components Height gauge connector (2) Height gauge (1) Ruler (3) Prosthesis holder (7) Forearm guide (6) Marker (4) Locking screw (8) Retroversion rod (5b) Retroversion rod (5a) NOTE : Height gauge and retroversion rod are assembled onto the stem holder depending on operative side and chosen approach. Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 22 surgical technique (3) 10.2 Assembly of Height Gauge Insert and push Assemble the height gauge (1) with the height gauge connector (2). (Fig. 25) (1) (2) Push the release button on the tip of the height gauge connector to insert the height gauge ruler (3). Assemble the height gauge marker (4) onto the height gauge ruler (3). Fig. 25 (4) (7) 10.3 Assembly of Prosthesis Holder Connect the height gauge to prosthesis holder (7) and secure the device with locking screw. (8) Two positions (fig 26a-b) are possible according to surgical approach used. Fig. 26a Secure the assembly to the trial stem or final stem with the locking screw (8). 10.4 Assembly of Retroversion Rod Fig. 26b (5) (5‘) Fig. 27 Connect retroversion rod (5‘) to retroversion rod (5) and attach the forearm guide (6). (Fig. 27) Identify the appropriate side (L for Left and R for right) and attach the retroversion rod (5) to prosthesis holder(7). (Fig. 28) (6) (5) Fig. 28 Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 23 color coding Humeral Side Trial Insert Ø 36 mm centered + 6 mm Ø 36 mm centered + 9 mm Ø 36 mm centered + 12 mm Ø 36 mm retentive + 6 mm Ø 36 mm retentive + 9 mm Ø 36 mm retentive+ 12 mm Ø 42 mm centered + 6 mm Ø 42 mm centered + 9 mm Ø 42 mm centered + 12 mm Ø 42 mm retentive + 6 mm Ø 42 mm retentive + 9 mm Ø 42 mm retentive+ 12 mm Color Reference MWD060 MWD061 MWD062 MWD970 MWD971 MWD972 MWD980 MWD981 MWD982 MWD983 MWD984 MWD985 Yellow Black Green Black Trial Inserts Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 24 color coding Diameter Color Ø 7 mm Ø 9 mm Ø 11 mm Ø 13 mm Ø 15 mm Yellow Green Blue Pink Gray Ref. Reamers MWD211 MWD212 MWD213 MWD214 MWD215 Ref. Final Stems DWD911 DWD912 DWD913 DWD914 DWD915 Ref. Trial Stems MWD911 MWD912 MWD913 MWD914 MWD915 Reamers Trial Stems Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 25 Ref. Long Stems L 170 mm L 180 mm L 210 mm DWD941 DWD942 DWD961 DWD943 DWD962 DWD944 DWD963 instrumentation Instrumentation - Humeral YKAD95 9 10 7 5 11 8 3 12 6 4 13 2 1 Ref. YRAD951 Cases Description Box / base Box / insert Box lid Instrumentation N° Description 1 Plug positioner 2 Humeral insert impaction handle 3 Tip for humeral insert impaction 4 Tip for impaction of non reversed hemi-prosthesis adaptor 5 Wrench for metaphyseal plug and union screw 6 Screwdriver 4.5 mm 7 Bone graft pliers 8 Ruler 200 mm 9 Humeral trial stem Ø 7 mm 10 Humeral trial stem Ø 9 mm 11 Humeral trial stem Ø 11 mm 12 Humeral trial stem Ø 13 mm 13 Humeral trial stem Ø 15 mm Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 26 Reference YRAD951 YRAD952 NCR009 Quantity 1 1 1 Reference MBO101 MWD421 MWD423 MWD424 MWD131 MWB012 MWA301 MDU502 MWD911 MWD912 MWD913 MWD914 MWD915 Quantity 1 1 1 1 1 1 1 1 1 1 1 1 1 instrumentation Instrumentation - Humeral YKAD95 3 4 7 2 8 9 20 10 21 5 11 22 23 13 14 15 16 17 18 24 1 4’ 6 19 12 25 Ref. YRAD952 Instrumentation N° Description 1 Prosthesis holder (Including nut MWD210) 2 Height gauge (including humeral lug MWD220) 3 Marker 4 Long retroversion pin 4‘ Short retroversion pin 5 Stabilizer 6 Metaphyseal reamer handle SZH 7 Ø 7 mm Diaphysis reamer 8 Ø 9 mm Diaphysis reamer 9 Ø 11 mm Diaphysis reamer 10 Ø 13 mm Diaphysis reamer 11 Ø 15 mm Diaphysis reamer 12 Ø 3.5 mm angled hexagonal screwdriver Reference MWD216 MWD217 MWD220 MWD218 MWD221 MWD219 MWB497 MWD211 MWD212 MWD213 MWD214 MWD215 MDM412 Quantity 1 1 1 2 or 1* 0 or 1* 1 1 1 1 1 1 1 1 Instrumentation Ø 36 mm N° Description 13 Ø 36 mmTrial spacer +9mm 14 Humeral Trial Insert Ø36 + 6mm 15 Humeral Trial Insert Ø36 + 9mm 16 Humeral Trial Insert Ø36 + 12mm 17 Retentive trial insert Ø36 mm + 6mm 18 Retentive trial insert Ø36 mm + 9mm 19 Retentive trial insert Ø36 mm + 12mm Reference MWD920 MWD060 MWD061 MWD062 MWD970 MWD971 MWD972 Quantity 1 1 1 1 1 1 1 Instrumentation Ø 42 mm N° Description 20 Humeral Trial Insert Ø42 + 6mm 21 Humeral Trial Insert Ø42 + 9mm 22 Humeral Trial Insert Ø42 +12mm 23 Retentive Trial Insert Ø42 + 6mm 24 Retentive Trial Insert Ø42 + 9mm 25 Retentive Trial Insert Ø42 + 12mm Reference MWD980 MWD981 MWD982 MWD983 MWD984 MWD985 Quantity 1 1 1 1 1 1 * Each set is provided with either 1 long and 1 short retroversion rod or 2 long retroversion rods Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 27 implants Humeral Implants Aequalis™-Reversed Fracture Stems Diameter 7 mm 9 mm 11 mm 13 mm 15 mm Length 130 mm 130 mm 130 mm 130 mm 130 mm Aequalis™-Reversed Fracture Long Stems* Reference DWD911 DWD912 DWD913 DWD914 DWD915 170 mm DWD941 180 mm 210 mm DWD942 DWD943 DWD944 DWD961 DWD962 DWD963 DWB010 Metaphyseal Plug Lateralized Humeral Inserts Diameter 36 mm 36 mm 36 mm 42 mm 42 mm 42 mm Diam.\ L 7 mm 9 mm 11 mm 13 mm Thickness + 6 mm + 9 mm + 12 mm + 6 mm + 9 mm + 12 mm Retentive Humeral Inserts Reference DWD860 DWD861 DWD862 DWD966 DWD967 DWD968 Diameter 36 mm 36 mm 36 mm 42 mm 42 mm 42 mm Thickness + 6 mm + 9 mm + 12 mm + 6 mm + 9 mm + 12 mm Reference DWD970 DWD971 DWD972 DWD976 DWD977 DWD978 Humeral Spacer Description Humeral spacer + 9 mm including tightening screw Reference DWD920 Non reversed Hemi-Prosthesis Description Non reversed hemi-prosthesis adaptor Including union screw metaphysis / adaptor Humeral Head CoCr Humeral Head CoCr Diameter 50 mm 52 mm Height 19 mm 23 mm Size Size 5 Size 5 Size 5 Length 36” 36” 36” Reference DWD922 DWD923 DWB251 DWB253 *Special request only. NiceLoop™ Ref single pack SMSL50101 SMSL50201 SMSL50301 Ref 12 pack SMSL50103 SMSL50203 SMSL50303 Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 28 Color Green White White/Green Needle KAC-25 KAC-25 KAC-25 notes Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 29 notes Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 30 notes Aequalis™ Reversed Fracture - Surgical Technique - UDKT134 31 US HEADQUARTERS MANUFACTURER Tornier, Inc 10801 Nesbitt Ave South Bloomington, MN 55437 USA +1 952 426 7600 INTERNATIONAL HEADQUARTERS TORNIER SAS 161 rue Lavoisier 38330 Montbonnot Saint Martin FRANCE +33 (0)76 61 35 00 www.tornier.com ©2015 Tornier, SAS. All rights reserved. Aequalis™, Aequalis™ Reversed Fracture,Niceloop™, Tornier™ and countries. are trademarks or registered trademarks of Tornier in the U.S. and other Prior to using any Tornier device, please review the instructions for use and surgical technique for a complete listing of indications, contraindications, warnings, precautions, potential adverse events, and directions for use. Aequalis™ Reversed Fracture - Surgical Technique - UDKT134